BEUDAMED
    FDA Adverse Event Injury Summary report: N

    MINICAP TRANSFER SET

    MDR report key: 2831958 · Received November 14, 2012

    Report

    Report Number
    1416980-2012-05088
    Event Type
    Injury
    Date Received
    November 14, 2012
    Date of Event
    September 1, 2012
    Report Date
    October 22, 2012
    Manufacturer
    BAXTER HEALTHCARE - MOUNTAIN HOME
    Product Code
    KDJ
    PMA / PMN Number
    K882498
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). CORRECTED INFORMATION: FURTHER INFORMATION WAS RECEIVED FROM A NURSE, WHO MEDICALLY CONFIRMED THIS REPORT. ON AN UNREPORTED DATE DURING HOSPITALIZATION, PD THERAPY WAS STOPPED AND THE PD CATHETER WAS REMOVED AS IT WAS OLD. ON AN UNKNOWN DATE, HEMODIALYSIS THERAPY WAS INITIATED. ON (B)(6) 2012 (PREVIOUSLY REPORTED AS (B)(6) 2012), THE PATIENT EXPERIENCED PERITONITIS. ON THAT SAME DAY, THE PATIENT WAS HOSPITALIZED FOR PERITONITIS (PREVIOUSLY REASON WAS NOT REPORTED). THE NURSE COULD NOT CLARIFY THE CULTURE RESULT AND THE CAUSE OF PERITONITIS. A BATCH REVIEW WAS CONDUCTED FOR THE POTENTIALLY ASSOCIATED LOT NUMBERS H12B06041 AND H12D23075. NO EXCEPTIONS WERE OBSERVED THAT WERE RELATED TO THE REPORTED CONDITION.

    Additional Manufacturer Narrative · 1

    (B)(4). THE PROBLEM WAS NOT CONFIRMED, AS NO SAMPLE WAS RETURNED FOR EVALUATION. THE CAUSE OF THE PERITONITIS WAS UNDETERMINED, AS NO DEVICE MALFUNCTION OR USE ERROR WAS IDENTIFIED DURING THE REPORT.

    Additional Manufacturer Narrative · 1

    (B)(4). THIS IS REPORT 2 OF 3 INVOLVED IN THIS PERITONITIS INCIDENT. THIS REPORT OF PERITONITIS WAS RECEIVED WITH NO ALLEGED DEVICE MALFUNCTION OR USE ERROR; THEREFORE, A SAMPLE WAS NOT REQUESTED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED.

    Description of Event or Problem · 1

    THIS REPORT WAS RECEIVED FROM GLOBAL PHARMACOVIGILANCE (GPV) AND IS A SPONTANEOUS REPORT FROM A CONSUMER IN THE USA OF CONSTIPATION AND PERITONITIS IN A PATIENT COINCIDENT WITH DIANEAL AND EXTRANEAL THERAPIES FOR PERITONEAL DIALYSIS (PD). DIANEAL AND EXTRANEAL THERAPIES WERE ONGOING. DURING A CALL WITH BAXTER CUSTOMER SERVICES, THE FOLLOWING WAS REPORTED. ON AN UNREPORTED DATE, THE PATIENT EXPERIENCED CONSTIPATION. ON (B)(6) 2012, THE PATIENT WAS HOSPITALIZED (REASON NOT REPORTED). ON (B)(6) 2012, THE PATIENT EXPERIENCED PERITONITIS. THE CAUSE OF PERITONITIS WAS CONSTIPATION. TREATMENT WAS NOT REPORTED. ON (B)(6) 2012, THE PATIENT WAS DISCHARGED FROM THE HOSPITAL. THE PATIENT WAS RECOVERING FROM THIS PERITONITIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 MINICAP TRANSFER SET SET, ADMINISTRATION, FOR PERITONEAL DIALYSIS, DISPOSABLE KDJ BAXTER HEALTHCARE - MOUNTAIN HOME

    Patients

    Seq Age Sex Outcome Treatment
    1 51 YR Hospitalization| O HOMECHOICE| DIANEAL PD4 AMBUFLEX| EXTRANEAL VIAFLEX